A Model for Vision Rehabilitation and the Role of the Physiatrist on the Interdisciplinary Team

In 2015, census data established that approximately 3.22 million people in the United States had a visual impairment and 1.02 million were blind¹ By 2050, the prevalence is expected to increase two-fold, as older adults will account for a much larger portion of the population.¹ A sizable number of these deficits can be ascribed to brain injuries, either acquired (stroke) or traumatic. Researchers who have studied acute stroke survivors report the prevalence of vision impairments to range between 65-72.8%.^2,3 and for traumatic brain injury to range between 9%-38%.⁴ Many reports have documented a lack of standardization for visual assessment within current practice guidelines.⁵ Roberts et al, in 2016 suggested that visual assessment should be comprehensive and integrated across the care continuum, within a suitable framework that promotes knowledge translation.⁶

WHAT IS THE GOAL OF USING A CONCEPTUAL MODEL FOR VISION REHABILITATION?

The conceptual model, (Figure 1), illustrates the importance of collaboration between the vision specialists and non-vision specialists to organize a systematic integration of assessments for both visual function and functional vision.⁶ A key aim of the article is to define terms that are critical to improve communication in relation to vision rehabilitation:

1. Visual function describes the function of the eye, the antecedent of the visual dysfunction, and represents the identification of a specific diagnosis or diagnoses to best describe the impairment (organ level).

2. Functional vision, or how vision interacts with sensory, physical and cognitive processes to create a top-down picture of the functional impact of the client’s visual dysfunction (impairment), their activity limitations such as difficulty reading, and their quality of life (person level).

3. Vision specialists diagnose impairments to visual function, which is often the root of the concern. These specialists are typically ophthalmologists and optometrists with advanced degrees in diagnosing and managing visual function.

4. Non-vision specialists are clinicians and practitioners who assess functional vision and may often be first to detect the presence of a visual dysfunction. They refer and consult with vision specialists to acquire the appropriate diagnosis and subsequently work cooperatively to create a comprehensive plan to maximize functional vision and quality of life. Best practices should include continuous evaluation and management. Non-vision specialists include physiatrists or physicians of various specialty areas, occupational therapists, physical therapists, speech-language pathologists, nurses, neuropsychologists, psychologists and recreation therapists.

Figure 1.

Conceptual Model for Vision Rehabilitation

WHAT ARE THE CONCLUSIONS OF USING A CONCEPTUAL MODEL TO GUIDE VISION REHABILITATION?

The conceptual model was organized to facilitate earlier inclusion of the vision specialist into current rehabilitation delivery models and systems; ideally, the initial evaluation should occur as close to the start or prior to the initiation of vision rehabilitation.⁴ The authors suggest the model can be used among professionals to guide integration of earlier visual assessment during the acute, inpatient, subacute rehabilitation, and community level outpatient services. When a non-vision specialist suspects visual dysfunction during an initial screen, a referral should be triggered to a vision specialist to establish early interprofessional collaboration. The referral should include vital information on the observed visual dysfunction and the functional limitations noted during activity.

ARE THERE STRENGTHS OR LIMITATIONS TO THE STUDY THAT ARE IMPORTANT IN INTERPRETING THE RESULTS?

A strength of this model is the foundation it provides, emphasizing the value of interprofessional assessment and treatment related to visual function and functional vision. The article also offers future directions for vision rehabilitation which are still appropriate and essential.

One limitation with this article is that the important role of physiatrists was not originally highlighted. Although the authors mention that this framework is applicable to all disciplines, the role of the physiatrists, specifically as part of the non-vision specialist team, was not emphasized. Physiatrists are core to the model; the physiatrist collaborates between vision and non-vision specialists while also acting as a liaison for the client to assure progress toward their vision goals. Physiatrists’ provide a unique perspective through holistic care, which importantly considers: (1) the body functions that are impacted, (2) the impact of these impairments on the functional use of vision, (3) how pharmacological prescriptions and other treatments may interact with intervention and (4) what available rehabilitative options may best facilitate the client in achieving their personal goals. Physiatrists also serve an ongoing role to monitor, manage, and reassess the client’s overall response to intervention and how to optimize quality of life. Furthermore, physiatrists play an integral role in promoting early utilization of vision specialists in the rehabilitation system.

HOW DOES THIS HELP IN CLINICAL PRACTICE?

The authors discuss interprofessional collaboration in the context of the vision assessment and management and how an improved dialog between professionals may lead to better patient outcomes. In addition, more optimal care planning avoids redundant diagnostics and evaluations and, ultimately, expedites the therapeutic process, which is cost-effective for the hospital system. Innovative solutions and high-quality care benefits collaborative work environments.⁷

TAKE-HOME MESSAGE

Roberts et al’s interprofessional model to guide practice can help improve vision assessment and treatment standards by: (1) conceptualizing assessment (2) encouraging earlier, more prevalent, and appropriate referral and intervention, and (3) facilitating improved interdisciplinary communication and collaboration. The article concludes that it is key to incorporate vision specialists into the care team and use standard language in daily practice. Routine assessment that includes the integration of both functional vision and visual function is important toto improve transitions across the continuum of care and foster consistency across practice centers.